Musculoskeletal Treatment Research Articles

Feasibility of a musculoskeletal ultrasound intervention to improve adherence in juvenile idiopathic arthritis: a proof-of concept trial

BackgroundNon-adherence is a prevalent and modifiable issue in juvenile idiopathic arthritis (JIA) that currently lacks provider-based intervention. Education surrounding disease status is one way in which families remain engaged in their care. Musculoskeletal ultrasound is one such form of demonstrative, real-time education that may impact the way patients and caregivers self-manage their disease. The aims of this study are to 1) assess the feasibility, acceptability and perceived usefulness of musculoskeletal ultrasound as a non-adherence intervention tool and 2) to examine changes in methotrexate adherence in adolescents with JIA following the ultrasound.MethodsEight adolescents with polyarticular or extended oligoarticular JIA and their caregivers completed this 12 week study. A within subject design was used to compare baseline and post-intervention adherence, quality of life and disease activity indices. Adherence measures included electronic measurement of methotrexate in addition to self-reported adherence questionnaires. The ultrasound intervention included a one-time, rheumatologist provided, educational examination of three or more currently or historically active joints.ResultsThe ultrasound intervention was found to be both feasible and acceptable. One hundred percent of eligible participants completed the ultrasound intervention. The ultrasound was well received by patients and caregivers, with most believing this to be a helpful tool. Baseline adherence was 75.3% among participants, with half of the participants being classified as non-adherent. Electronically measured and self-reported adherence measures did not show significant changes during the post-intervention period. Two participants improved, four participants maintained, and two participants decreased adherence. On ultrasound, 18/27 (66.7%) of the examined joints displayed abnormalities, with 63% being discrepant and additive to the rheumatologist’s physical examination.ConclusionsWhile our intervention did not show any changes in adherence, quality of life or disease activity indices in this proof-of-concept trial, the intervention does show promise in acceptability measures and merits future study in a more robust trial design. An additional study benefit was that the musculoskeletal ultrasound intervention was able to demonstrate subclinical disease, leading to clinically impactful therapeutic changes in several participants.

Association between musculoskeletal pain at multiple sites and objectively measured physical activity and work capacity: Results from UK Biobank study

ObjectivesTo describe the cross-sectional association between musculoskeletal pain at multiple sites and physical work capacity (PWC) and objectively measured physical activity (PA). DesignObservational study. MethodsData from a subsample of the UK Biobank were utilised (n=9856; mean age 58.5 years, mean body mass index 30.2kg/m2, 62% female). PWC was measured by a bicycle ergometer and PA by an accelerometer. Pain experienced in hip, knee, back and neck/shoulder was collected by questionnaire. Linear regression modelling was used with adjustment for potential confounders to estimate the association between pain and PWC and PA. ResultsIncrease in number of painful sites was associated with lower PWC, moderate and vigorous PA and increased low intensity PA in a dose-response relationship (all p-values for trend ≤0.001) before and after adjustment for confounders. In site specific analyses, hip pain was associated with an increased low intensity PA (β 52.8min/week, 95% CI 2.3–103.2) and reduced moderate PA (β −50.1min/week, 95% CI −98.5 to −1.8). Knee pain was only associated with vigorous PA (β −5.7min/week, 95% CI −10.0 to −1.3). Pain at neck/shoulder pain and back were not independently associated with PWC and PA. ConclusionsGreater number of painful sites is consistently associated with poorer PWC, increased low intensity PA and reduced moderate to vigorous PA. Clinicians should address the critical role of being physically active in managing chronic musculoskeletal pain and interventions targeting musculoskeletal pain may be needed to increase PA levels.

Therapeutic Intervention in Musculoskeletal Radiology: Current Practice and Future Directions.

Over the last several decades, the volume and range of therapeutic musculoskeletal (MSK) interventions that radiologists can offer their patients has dramatically increased. With new materials and improving imaging modalities, as well as significant investment in research, the field of MSK interventional radiologic intervention will likely continue to expand. In this article, we summarize the range of interventions currently available to the MSK radiologist. We also seek to explore new and emerging techniques that may become commonplace in the near future while considering the challenges that may lie ahead in the field of MSK radiology.

Ethics in musculoskeletal regenerative medicine; guidance in choosing the appropriate comparator in clinical trials

Regenerative Medicine (RM) techniques aimed at the musculoskeletal system are increasingly translated to clinical trials and patient care. This revolutionary era in science raises novel ethical challenges. One of these challenges concerns the appropriate choice of the comparator in (randomized controlled) trials, including the ethically contentious use of sham procedures. To date, only general guidelines regarding the choice of the comparator exist. To provide specific guidelines for clinical trial comparator choice in musculoskeletal RM. In this manuscript, we discuss the ethics of comparator selection in RM trials. First, we make a classification of RM interventions according to different health states from disease prevention, return to normal health, postponing RM treatment, supplementing RM treatment, substituting RM treatment, improving RM outcome, and slowing progression. Subsequently, per objective, the accompanying ethical points to consider are evaluated with support from the available literature. a sham procedure is demonstrated to be an ethically acceptable comparator in RM trials with certain objectives, but less appropriate for musculoskeletal RM interventions that aim at preventing disease or substituting a surgical treatment. The latter may be compared to 'standard of care'. From a scientific perspective, choosing the correct comparator based on ethical guidelines is a step forward in the success of musculoskeletal RM.

Directional preference of the extremity: a preliminary investigation

ABSTRACTBackground: Mechanical diagnosis and therapy (MDT) is a specific classification-based musculoskeletal examination and intervention system that uses repeated end range and sustained movement to classify patients into mechanical syndromes. Research has recently demonstrated increased prevalence, reliability, and efficacy of MDT syndromes in varied peripheral musculoskeletal populations. There is currently no research analyzing if predictive variables exist for establishing directional preference in peripheral joints, other than the wrist. The aim of this study was to examine the clinical application of predictive variables for establishing directional preference and spinal referral in patients with isolated peripheral joint pain.Case Description: Thirty-seven consecutive patients with isolated peripheral pain were evaluated and classified using MDT assessment. Secondary analysis of predetermined variables was performed for association with directional preference and identification of spinal referral in Derangement syndrome.Results: All 37 patients were classified using MDT assessment. Thirty-three (89.2%) were classified as Derangement syndrome: 17 as spinal Derangement (45.9%) and 16 as peripheral Derangement (43.2%). One peripheral derangement also had an underlying Articular Dysfunction. Additionally, there were four patients classified as Other (10.8%).Discussion: Historical and physical examination findings were analyzed to determine if there were associated variables of directional preference or spinal referral. Mechanical stress was found to be the most associated factor in predicting directional preference. No peripheral movement loss, paresthesia, and constant pain were more associated with spinal referral. These findings may lead to a greater understanding of peripheral MDT assessment, which may lead to increased identification of directional preference and improved patient outcomes.Level of Evidence: 4

Augmented and Virtual Reality Navigation for Interventions in the Musculoskeletal System

Augmented reality (AR) and virtual reality (VR) are cutting-edge technologies that offer advanced navigational solutions. These systems are just starting to be used in interventional radiology and the literature has been limited to pre-clinical and translational experiments. In this paper, we present a review of AR and VR for musculoskeletal interventions. Mixed reality systems have evolved from costly research systems to fully commercialized clinical instruments designed to facilitate operators in navigating complex anatomy. Studies within interventional radiology have demonstrated safety, improved accuracy, and decreased exposure to ionizing radiation. We review the progression of mixed reality systems from their early origins in computer science through their current day surgical applications, with a special focus on landmark studies within radiologic interventions for the musculoskeletal system. We highlight the instrumentation, clinical workflow, benefits and drawbacks, and suggested future directions for the two main AR systems: head-mounted display and image-overlay.

AB030. 239. Pharmacological agents in musculoskeletal intervention: efficacy, safety, and recommendations

AB030. 239. Pharmacological agents in musculoskeletal intervention: efficacy, safety, and recommendations

Prevalence and distribution of musculoskeletal disorders in firefighters are influenced by age and length of service

Introduction: The objective of this cross-sectional study is to describe the prevalence and severity of self-reported musculoskeletal disorders (MSDs) in firefighters and how these vary by demographics and length of service (LOS). Methods: A cohort of 294 active-duty firefighters completed a body diagram to indicate the location and pain intensity of their MSK complaints. Where painful sites were indicated, they completed the relevant region-specific self-report disability measure – Neck Disability Index (NDI), Roland Morris Disability Questionnaire (RMDQ), Lower Extremity Functional Scale (LEFS), or the Short Form of Disabilities of the Arm, Shoulder and Hand (QuickDASH) – to quantify severity. Prevalence was determined from the body diagrams and severity from the site-specific self-report questionnaires. Differences in MSK severity based on demographics or LOS were determined using ANOVA. Results: The 294 active-duty firefighters had a mean age of 42.6 (SD 9.7) years and mean duration of service of 15.1 (SD 10.1) years. The prevalence of neck, back, upper-limb, and lower-limb complaints was 20%, 33%, 44%, and 45% respectively. Firefighters 42 years or older reported significantly more severe lower-extremity disability (median (IQR) LEFS: 71 (65, 77) vs. 75 (69.5, 78.5), p=0.03) and more severe back disability (median (IQR) RMDQ: 2 (1, 3) vs. 1 (0, 2), p=0.04). Firefighters with 15 years or more of firefighting service reported significantly more severe lower extremity disability (median (IQR) LEFS: 71 (64, 77) vs. 76 (70, 79), p=0.0005). Firefighters reporting >1 MSDs were significantly older than firefighters reporting no MSD ( F(5,285)=3.3, p=0.002). Discussion: The rate of MSDs is high in firefighters, and their severity is elevated with greater age and LOS, suggesting cumulative exposures/injuries and highlighting the need for ongoing assessment of the musculoskeletal system and interventions to reduce injury throughout firefighters' careers.

Should musculoskeletal injury prevention interventions target personal and/or organizational factors?

Introduction: The nature of musculoskeletal injuries (MSKI) in the military setting is multi-factorial and complex, with risks relating both to personal and organizational factors. With back pain constituting one of the most common MSKI affecting Swedish Armed Forces (SAF) marines, including their work ability, preventive actions are highly warranted. Such preventive actions traditionally target factors related to the individual, but attention should also be focused on organizational factors to fully promote effective prevention. This session aims to present identified risks for back pain limiting work-ability in SAF marines and its possible generalizability to other similar groups, and to illustrate and discuss when prevention, primary-to-tertiary, are likely to be effective when also targeting factors related to the organizational level.

Navigating emerging biotechnology interventions in sports and exercise medicine – Where innovation meets the evidence and the patient

Background: With Sport and Exercise Medicine a relatively new medical Specialty and a desire for our community to age healthier, longer and more active, the onus is now on Sport and Exercise Medicine practitioners and the multidisciplinary team to help the community achieve these goals. New advances in biotechnology have given hope to both practitioners and patients to be the magic bullet for degenerative musculoskeletal conditions such as osteoarthritis and tendinopathy. But whilst these emerging interventions show promise, the evidence base is yet to back these claims up. I will explore the history behind autologous interventions for such conditions including blood, platelet rich plasma, tenocyte implants and stem cell interventions for musculoskeletal interventions and the role and challenges the Australasian College of Sport and Exercise Physicians (ACSEP) has had in the evolution of these in current clinical management paradigms.

A cross-sectional examination of the profile of chiropractors recruited to the Australian Chiropractic Research Network (ACORN): a sustainable resource for future chiropractic research

ObjectivesThe Australian Chiropractic Research Network (ACORN) practice-based research network (PBRN) cohort was established to provide sustainable infrastructure necessary to address lack of rigorous investigation and to bridge the research–practice gap...

Ultrasound-guided injections in primary care: evidence, costs, and suggestions for change.

Musculoskeletal (MSK) ultrasound has been used increasingly over the past decade, by non-radiologist hospital doctors, extended scope physiotherapists (ESPs), and to a lesser extent by GPs in primary care, both for diagnostic purposes and to guide therapeutic interventions. The reduction in equipment costs, together with improved image resolution and an increase in educational opportunities, seem to have facilitated these changes. MSK ultrasound is a highly effective diagnostic modality and is regularly used in secondary care to guide MSK interventions including joint and soft-tissue injections. Recent evidence, based on large randomised controlled trials (RCTs) and meta-analyses, demonstrates improved accuracy, efficacy, and cost-effectiveness of ultrasound-guided joint and MSK soft-tissue injections when compared with landmark-guided injections (LMGIs). In 2015 the American Medical Society for Sports Medicine (AMSSM) published a position statement reviewing the current evidence for ultrasound-guided injections (USGIs), focusing on the accuracy, efficacy, and cost-effectiveness of these interventions.1 It demonstrated high-quality evidence that USGIs are more accurate than ‘blind’ or LMGIs and ‘good’ evidence that USGIs are more effective than LMGIs specifically for large joints, inflamed joints, subacromial bursitis, carpal tunnel syndrome, and de Quervain’s tenosynovitis (Figure 1). There was also limited evidence …

Acute joint pain in the emerging green collar workforce: Evidence from the linked National Health Interview Survey and Occupational Information Network (O*NET).

Green jobs are a rapidly emerging category of very heterogeneous occupations that typically involve engagement with new technologies and changing job demands predisposing them to physical stressors that may contribute to the development of joint pain. We estimated and compared the prevalence of self-reported acute (past 30 days) joint pain between green and non-green collar workers using pooled 2004-2012 National Health Interview Survey (NHIS) data linked to the Occupational Information Network Database (O*NET). Green collar workers have a higher prevalence of acute joint pain as compared to non-green collar workers. Green collar workers with pain in the upper extremity joints were significantly greater than in the non-green collar workforce, for example, right shoulder [23.2% vs 21.1%], right elbow [13.7% vs 12.0%], left shoulder [20.1% vs 18.2%], and left elbow [12.0% vs 10.7%]. Acute joint pain reported by the emerging green collar workforce can assist in identifying at risk worker subgroups for musculoskeletal pain interventions.

The Potential Use of Ultrasound-Magnetic Resonance Imaging Fusion Applications in Musculoskeletal Intervention.

We sought to assess the potential use of an application allowing real-time ultrasound spatial registration with previously acquired magnetic resonance imaging in musculoskeletal procedures. The ultrasound fusion application was used to perform a range of outpatient procedures including piriformis, sacroiliac joint, pudendal and intercostal nerve perineurial injections, hamstring-origin calcific tendonopathy barbotage, and 2 soft tissue biopsies at our institution in 2015. The application was used in a total of 7 procedures in 7 patients, all of which were technically successful. The ages of patients ranged from 19 to 86 years. Particular use of the fusion application compared to sonography alone was noted in the biopsy of certain soft tissue lesions and in perineurial therapeutic injections.

Enhancing Palpation Skills Through the Use of Stereognosis Drills

Context: Musculoskeletal palpation is taught in our athletic training programs as part of the injury evaluation process. However, as palpation skills are taught, the focus is oftentimes on accuracy of surface-anatomy landmarks instead of the ability to discriminate qualitative information such as tissue tone, spasm, or pain response from the soft tissue. Because palpation is foundational for evaluation and intervention, a need exists for further development of this skill. Objective: Provide educators with instructional techniques to enhance palpation skills. Background: Manual medicine techniques are increasingly common in athletic training and require superb palpation and soft tissue discrimination skills. The ability to detect large and small differences in tissue qualities during orthopaedic evaluation can lead to a more accurate assessment as well as enhance manual medicine intervention techniques. Description: We describe 4 activities to enhance palpation skills (coin discrimination, sheet tension, vacuum-immobilizer assembly, and spring-scale compression). Each activity is presented with progressions to improve the foundation of a student's palpation skills and provide advanced training to better refine palpation skills. Clinical Advantage(s): Integrating tasks to improve palpation skills throughout the athletic training curriculum may help improve student confidence, accuracy, and precision while performing patient evaluation and manual medicine interventions. Improved ability to detect and discriminate musculoskeletal pathology can lead to more accurate assessment and efficient intervention techniques. Conclusion(s): Palpation is an essential skill in musculoskeletal evaluation and intervention. With consistent and progressive instruction, this skill can be practiced and refined, improving student confidence and skill application.

Collaborating with cardiac sonographers to develop work-related musculoskeletal disorder interventions

For more than two decades, surveys of imaging technologists, including cardiac sonographers, diagnostic medical sonographers and vascular technologists, have consistently reported high prevalence of work-related musculoskeletal discomfort (WRMSD). Yet, intervention research involving sonographers is limited. In this study, we used a participatory approach to identifying needs and opportunities for developing interventions to reduce sonographers’ exposures to WRMSD risk factors. In this paper, we present some of those needs. We include descriptions of two interventions, targeted for cardiac sonographers, that were developed, through an iterative process, into functional prototypes that were evaluated in pilot tests by practicing sonographers. One of these interventions is now in daily use. We would like other engineers and ergonomists to recognise this area of opportunity to apply their knowledge of biomechanics and design in order to begin to address the high prevalence of WRMSDs in sonographers, by working with sonographers to develop useful and usable interventions.Practitioner Summary: This paper discusses needs, opportunities and methods for working with sonographers in order to develop interventions to reduce their exposure to risk factors for work-related musculoskeletal discomfort. Results from field tests of two novel interventions targeting cardiac sonographers are also presented.

Ultrasound guided musculoskeletal interventions: professional opportunities, challenges and the future of injection therapy

AbstractThe demand for ultrasound guided injections for musculoskeletal presentations has increased in recent years as practitioners and patients seek verification of needle position. Musculoskeletal management pathways regularly include injection therapy for pain relief and are sometimes indicated as a single intervention but may need to be supported by rehabilitation. Workload in radiology departments has expanded in volume and complexity as radiologists perform new interventional procedures that require medical expertise. Innovative responses are required to meet the demand for ultrasound guided musculoskeletal injections; one option is offering appropriate education to musculoskeletal sonographers, enabling them to extend their current scope of practice. The role of the extended scope physiotherapist in the United Kingdom provides evidence that role diversification can produce excellent patient outcomes whilst preserving financial resources. The professional, legal and clinical requirements of extending service provision to include new clinical staff presents challenges that have to be met with strong leadership and the provision of high quality education in ultrasound guided interventions. There are many indicators that the patient experience is enhanced by guiding musculoskeletal injections, and access to this service has impact on patients' confidence in their treatment pathway.

Human arm posture prediction in response to isometric endpoint forces

The ability to predict the musculoskeletal response to external loads has multiple applications for the design of machines with a human interface and for the prediction of outcomes of musculoskeletal interventions. In this study, we applied an inverse–inverse dynamics technique to investigate its ability to predict arm posture in response to isometric hand forces. For each subject, we made a three-dimensional musculoskeletal model using the AnyBody Modelling System (AMS). Then, we had each subject-specific model hold a weight anteriorly to the right shoulder joint at a distance of half of the arm length. We selected the glenohumeral abduction angle (GHAA) as the only free parameter. Subsequently, we used inverse–inverse dynamics to find the optimal GHAA that minimised a performance criterion with physiological constraints. In this study, we investigated the performance of two different objective functions: summation of squared muscle activity (SSMA) and summation of squared normalised joint torques (SSNJT). To validate the simulation results, arm posture responses to different isometric downward hand forces were measured for six healthy male subjects. Five trials were performed for each loading condition. The results showed that, with an increase in hand load, there was a reduced GHAA in all subjects. Another interesting finding was that self-selected postures for lighter tasks varied more than postures for heavier tasks for all subjects. To understand this, we investigated the curvature of the objective function as a function of the load and observed an increased curvature with increased load. This may explain the reduced intra-subject variations observed for increasing loads.

MRI-guidance in percutaneous core decompression of osteonecrosis of the femoral head.

The purpose of this study was to evaluate the usefulness of MRI-guidance for core decompression of avascular necrosis of the femoral head. Twelve MRI-guided core decompressions were performed on patients with different stages of avascular necrosis of the femoral head. The patients were asked to evaluate their pain and their ability to function before and after the procedure and imaging findings were reviewed respectively. Technical success in reaching the target was 100 % without complications. Mean duration of the procedure itself was 54 min. All patients with ARCO stage 1 osteonecrosis experienced clinical benefit and pathological MRI findings were seen to diminish. Patients with more advanced disease gained less, if any, benefit and total hip arthroplasty was eventually performed on four patients. MRI-guidance seems technically feasible, accurate and safe for core decompression of avascular necrosis of the femoral head. Patients with early stage osteonecrosis may benefit from the procedure. • MRI is a useful guidance method for minimally invasive musculoskeletal interventions. • Bone drilling seems beneficial at early stages of avascular necrosis. • MRI-guidance is safe and accurate for bone drilling.

Perspectives in ultrasound-guided musculoskeletal interventions.

Ultrasonography (USG) is a safe, easily available, and cost-effective modality, which has the additional advantage of being real time for imaging and image-guided interventions of the musculoskeletal system. Musculoskeletal interventions are gaining popularity in sports and rehabilitation for rapid healing of muscle and tendon injuries in professional athletes, healing of chronic tendinopathies, aspiration of joint effusions, periarticular bursae and ganglia, and perineural injections in acute and chronic pain syndromes. This article aims to provide an overview of the spectrum of musculoskeletal interventions that can be done under USG guidance both for diagnostic and therapeutic purposes.